Public policy questionnaire

* required field

How do you wish to be contacted?
(Please fill in as many contact options as possible)

Email address* Phone number Fax number

Mailing address*

Which of the following child advocacy issues interest you?
(You may check as many boxes as you wish)

Medicaid Funding Prevention of Youth Access to Tobacco Pediatric Research Funding Prenatal HIV Testing and Counseling Early Intervention Child Health Insrance Program/KidCare Program Graduate Medical Education(GME) funding for children's hospitals Unintentional Injury Prevention School-Based Health Clinics Child Abuse and Neglect Organ Transplantation Childhood Asthma Welfare Reform Lead Poisoning Immunizations Managed Care Policies and Practices Chronic Illness Other (please specify)

How do you wish to be involved in Children's Memorial lobbying efforts/initiatives?
(You may check as many boxes as you wish)

Write elected or appointed officials*

Call elected or appointed officials*

Meet individually with elected or appointed officials*

Testify at a legislative hearing

Submit an op-ed column or letter to the editor of a local newspaper

Participate in a group meeting with elected and appointed officials

Volunteer to help with mass mailings

Facilitate grassroots lobbying by being my department's contact person (For Children's Memorial Hospital employees only)

Other (please specify):

*In the box below, please list any legislators or government officials at the federal, state and local levels with whom you have a relationship.

Or click here for a list of legislators and state officials

Thank you very much for your time. We appreciate your willingness to assist Children's Memorial with public policy and advocacy initiatives. We will contact you very soon.

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